Index

This week the nations of the
world are gathered in Geneva for the sixty-sixth session of the World Health
Assembly (WHA). The eight-day gathering can be thought of as the legislative
proceedings of the World Health Organization (WHO), during which Ministries of
Health, donors and NGOs haggle over individual words located within barely
penetrable documents, often arguing through all-night sessions fueled by Swiss
pizzas. The WHA is a notoriously painful experience, but it is a sort of
democracy in action. Far from proportional representation, each country, from
miniscule Vanuatu to behemoth China, has an equal vote. Behind the scenes lobbyists
– in the form of major donors, civil society groups, various UN agencies and
affiliates – urge official country delegations to consider their perspectives.
And in the end, grand compromises may be reached, forcing a donor as
significant as the U.S. government to buckle under to the demands of an
alliance of left-leaning NGOs, BRICS countries, and perhaps an obscure group of
physicians. Such things have happened.

Denis Balibouse/Reuters

It is the job of the WHO
Director-General’s (DG) office to set the stage and tone of the WHA through
carefully prepared advance documents, especially the agency’s proposed two-year
budget. The political directions the DG hopes to tilt WHA members towards are
best reflected in her budget outline.

Yesterday the WHA officially
opened, and DG Margaret Chan entered with a strong hand. She recently started
her second term of office, having run virtually unopposed – only token
unsupported candidates ran in her reelection. Chan enjoys strong backing from
the three most powerful members of the WHO: the U.S., U.K., and China. And
though the budget of WHO is woeful, as I
will show in this and subsequent blog posts this week, Chan has the power
to persuade the WHA to approve new directions in Global Health through her choices
in apportioning funds.

Overall, Chan’s options are
limited by two factors. First, it has been more than 28 years since the members
of the WHA have voted in favor of an increase in their base assessments.
Essentially dues for membership, the assessments are determined through a basic
algorithm nation-by-nation, roughly based on GDP. Since the member states
refuse to allow their basic dues to increase, the WHO’s core budget has
steadily decreased in size over the
last two decades when adjusted for inflation. Moreover, the assessments are
paid in US dollars, but the WHO’s Geneva operations and salaries are paid out
in much-inflated Swiss francs. The second challenge to Chan’s budget stems from
the 2008 financial crisis and on-going world recession: her voluntary donation
pool has plummeted. Major donors, especially the U.S., have always supplemented
their assessments with far more substantive donations that target specific
programs or agendas. This out-sized influence on the part of key donors has
always been a source of tension within both the WHA and Global Health, writ
large: Most have viewed it as a necessary evil. That “evil” diminished
significantly in the post-2008 economic climate and by 2010 the WHO was in dire
straits. (More on that below and in
subsequent blog posts.)

According to the WHO’s budget
documents submitted this week to the WHA, the agency’s expenditures actually
started to eclipse its revenues in 2007, and by 2010 DG Chan faced a
significant deficit. About $1 billion was cut from 2011-12 spending, and the
agency laid off or left unfilled about 20 percent of staff positions, mostly in
its Geneva headquarters.

Chan initiated a series of reform
measures against this financial background. Her reforms – long needed in
general, but debated in detail – have yet to measure up to the far more
sweeping changes suggested by outsiders, especially in the Chatham House process.
Chan’s initiatives unfolded not only against the background of stiff financial
difficulties for the WHO, but scandals surrounding the other large Geneva-based
health programs, GAVI (the Global Alliance of Vaccines and Immunizers) and the
Global Fund to Fight AIDS, Tuberculosis and Malaria. Both of those
organizations faced donor anger amid allegations of corruption and
incompetence. Over the last five years, both have undergone significant reform
in their financing and function. GAVI is now in such strong shape that its
budget well exceeds that of the WHO, and the Global Fund is facing a
replenishment round this fall, calling for a $15 billion package of donor
support.

In her budget proposal to the WHA
this week Chan reflects on the need for reform, aimed at enhancing the agency’s
credibility, by promising accountability and outcomes measurement, as
delineated in this flow chart:

Overall, the proposed WHO 2014-15 budget offers startling changes in the mission and direction of the agency,
pushing it significantly away from infectious diseases, HIV, TB, malaria, and
outbreaks, and towards addressing disabilities, diabetes, heart disease, cancer,
and aging.

Increase spending on noncommunicable disease
programs by +20.5%, with disabilities and rehabilitation getting the largest
boost, +60%.

Institute a programmatic approach dubbed,
“Promoting Health Through the Life-Course,” which is an educational/prevention
package, garnering almost a +10% increase, with the largest boost going to
aging and health – an enormous +125% budget increase.

Support health systems development and
improvement – counseling governments on actions to benefit their care-giving –
gets a +8.4% boost.

Support a variety of management and leadership
efforts, garnering a +10% increase.

Perhaps the most confusing
budgetary dichotomy is that between preparedness and response for crises:

The lion’s share of that is directed at
supporting countries in their efforts to meet the surveillance and disease
alert capacities outlined in the 2005 International Health Regulations (IHR). Countries
were supposed to meet those guidelines by 2012, but 117 nations formally
requested more time, and only thirteen fully reached all criteria on deadline.
WHO would spend about $287 million to assist countries in training and
development necessary to abide by the IHR.

But the WHO will greatly reduce its own
institutional capacity to respond to outbreaks, epidemics and humanitarian
crises, cutting its crisis response budget by -51.4%.

The text of the proposed DG
budget does little to explain why these shifts in spending, and therefore in
the entire mission of the WHO, are recommended. Presumably the enormous boost
in noncommunicable diseases foci reflects last year’s resolutions on the matter
passed by the UN General Assembly.

But it is curious that in this
final countdown to the 2015 deadline for the Millennium Development Goals the
DG seeks to radically reduce spending
on HIV and TB, has no specific maternal health or child development line in the
primary budget (though they are in appendices), and seems confident that the
MDGs can be attained without significant spending. Presumably this confidence
reflects assumptions that other entities (Global Fund, GAVI, UNICEF, World
Bank, USAID, Roll Back Malaria, PEPFAR) will pick up the slack.

The tuberculosis cuts are
especially mysterious, as the numbers of individuals worldwide getting
treatment have increased substantially over the decade, but so has incidence of
multi-drug resistant TB. Worse, XDR-TB, a virtually untreatable form of the
bacterial disease, can now be found all over the world, though it was
nonexistent (or at least unknown) ten years ago. WHO is drastically reducing
its spending on TB, and so is the world's other major donor, USAID. Due to
sequestration, all US global health programs are currently experiencing a -5.1%
reduction in spending, and Congress has yet to agree on a FY2014 budget.
President Obama's proposed 2014 budget would cut
TB programs at USAID by -19% and leaves
PEPFAR-based spending stagnant. The Global Fund will not know how much
money it has available to direct to TB until after its fall replenishment
summit with donors. Even if the Fund attains its $15 billion target, most of
its resources will go to HIV treatment, and none of the funds would be
dispersed until late 2014, leaving a large potential hole in backing for TB
efforts. Drug stock-outs are being experienced all over the world for TB meds,
in part due to manufacturing problems. Without sufficient funds, it seems
likely TB programs will muddle through with less-than-perfect drug cocktails,
breeding still more strains of MDR and XDR tuberculosis. We could reach 2016
with the dismal recognition that budget shifts made this year had devastating
impact on Humanity's centuries-old fight with the mycobacterium.

The budget would also seem to
assume that countries, rich and poor, will meet the surveillance and response
capacities of the International Health Regulations, and handle outbreaks
largely on their own. The WHO response budget is slashed. In her
speech opening the WHA this week Chan noted that the H7N9 influenza
outbreak in China came dangerously close to pandemic stage, and that “nobody
can predict” what that virus will do over the coming months. The Kingdom of
Saudi Arabia has requested special discussion of the novel coronavirus (MERS)
outbreak in that country, spawning a SARS-like epidemic that continues to swell
at this writing. Both China and Saudi Arabia have systems in place that meet
the IHR, yet each country requested outbreak assistance from the WHO.

It seems to this writer that the
WHO’s decision to increase spending in noncommunicable diseases at the apparent
expense of its own capacity to respond to outbreaks and epidemics is hasty. The
world is not yet ready to walk away from Humanity’s war with the microbes.